Treating Acne Scars With Subcision

Acne scars can linger long after active breakouts have healed, leaving many people feeling frustrated with their skin’s appearance. These scars come in various forms, from shallow depressions to deep, tethered scars that alter the skin’s texture.

For those dealing with persistent acne scars, subcision has emerged as an effective treatment, particularly for more severe forms of acne scarring. In this post, we will explore subcision as a solution for acne scars, its benefits, and what to expect before, during, and after the procedure.

What are Acne Scars?

Acne scars are the result of inflammation within the dermis caused by acne. When the skin experiences trauma — such as the swelling and rupture of acne lesions — it attempts to heal itself. However, this process can sometimes result in excessive tissue loss (atrophic scars) or overproduction of tissue (hypertrophic scars).

• Causes: Severe acne, including cysts and nodules, often leads to scarring due to the damage done to deeper layers of the skin. Other causes include the skin’s individual healing response, prolonged inflammation, and even picking or popping pimples.
• Appearance: Acne scars typically appear as depressions or indentations in the skin (atrophic scars), or raised, thickened areas (hypertrophic or keloid scars). They can vary in size and depth, giving the skin an uneven texture.
• Psychological impact: Beyond the physical appearance, acne scars can significantly affect self-esteem and confidence. A study published in Dermatologic Surgery reported that 92% of people with acne scars experienced reduced quality of life, with impacts on social interactions, relationships, and overall well-being.

Subcision: A Game-Changer for Acne Scars

Subcision is an effective treatment option specifically designed to address the deeper, more stubborn acne scars. It is particularly helpful for scars that are “tethered,” meaning they are attached to deeper layers of tissue, creating visible depressions on the skin’s surface.

What is Subcision?

Subcision is a minimally invasive surgical procedure designed to improve the appearance of atrophic acne scars, such as rolling scars and tethered boxcar scars. The treatment involves using a specialized needle to release the fibrous bands beneath the skin, which are pulling the scar down.

• How it works: A needle is inserted under the scar to break up the fibrous tissue responsible for tethering the skin to deeper layers. Once these bands are released, the skin is free to rise, creating a smoother surface. Over time, new collagen forms in the treated area, further improving the texture and appearance of the scar.
• Uses: Subcision is not only effective for acne scars but is also used for other skin conditions such as cellulite. It is especially beneficial for treating acne scars because of its ability to target the underlying cause of the indentation.
• Best for certain types of scars: Subcision works best for rolling scars and tethered boxcar scars. These types of scars are characterized by their broad, shallow depressions with soft edges or tethered areas.
• Limitations: While subcision is effective for many types of scars, it is not suitable for all. It is not a recommended treatment for ice-pick scars (which are deep and narrow) or for red or pigmented scars, stretched scars, or keloid scars.

How Subcision is Performed

Subcision is a relatively straightforward procedure performed in a dermatologist’s office. Here is a step-by-step look at how it works:

1. Local anesthesia: The area to be treated is numbed with a local anesthetic to ensure the patient is comfortable throughout the procedure.
2. Needle insertion: A special needle, usually a Nokor needle, is inserted into the skin, targeting the area beneath the scar.
3. Breaking fibrotic strands: The needle is maneuvered under the scar to sever the fibrous tissue tethering the scar to the underlying layers. This releases the tension, allowing the skin to rise and appear smoother.
4. Post-treatment options: Often, subcision is combined with other treatments like microneedling or dermal fillers to enhance the results further. Fillers can be injected into the newly released area to plump up the skin and promote faster healing.

Benefits of Subcision for Acne Scars

Subcision offers numerous benefits for individuals looking to improve their skin’s texture without the need for invasive surgery.

• Minimally invasive: Unlike more invasive procedures like laser treatments or surgical scar removal, subcision involves only a small needle, making it a minimally invasive option.
• Long-term improvement: The release of fibrotic bands allows the skin to gradually heal and produce new collagen, leading to long-term improvement in skin texture.
• Combination therapy: Subcision can be combined with other treatments such as microneedling, laser therapy, or fillers to enhance results and address multiple aspects of scarring.

What to Expect During and After Subcision

Understanding what the subcision process involves can help you prepare for the procedure and manage expectations.

• Pre-procedure preparation: Before the treatment, patients should avoid any blood-thinning medications or supplements (e.g., aspirin, ibuprofen) to minimize the risk of excessive bruising.
• During the procedure: The procedure typically lasts about 30 minutes to an hour. Discomfort is minimal due to local anesthesia, but patients may feel some pressure or tugging as the needle breaks the fibrous bands beneath the skin.
• Post-procedure recovery: After the procedure, patients may experience swelling, bruising, and tenderness in the treated areas. This is normal and usually resolves within 5–7 days. The downtime is minimal, but it is important to avoid strenuous activity or anything that might disturb the healing process for a few days.
• Results timeline: Some initial improvement may be seen within a few days as the skin begins to heal. However, full results will become more apparent over the course of several weeks to months as collagen production increases.
• Are results permanent? The results of subcision are long-lasting, particularly for scars that were tethered. While no treatment can fully “erase” scars, subcision offers significant improvement in skin texture that can last for years.

Who is a Good Candidate for Subcision?

Subcision is best suited for individuals with specific types of acne scars:

• Types of scars: Rolling scars and tethered boxcar scars respond particularly well to subcision, as these scars are caused by fibrotic bands that can be physically released.
• Ideal patient profile: Patients with moderate to severe scarring, good overall skin health, and realistic expectations are the best candidates. Subcision works on most skin types and tones, but the severity of scarring will determine the need for additional treatments.
• Who should avoid subcision? Patients with active acne, certain medical conditions, or those prone to keloid scars should avoid subcision, as it may not provide the desired results or could worsen their condition.

Potential Risks and Side Effects

As with any medical procedure, subcision comes with risks, though they are generally minimal.

• Common side effects: Swelling, bruising, and temporary discomfort are the most common side effects. These typically resolve within a few days to a week.
• Rare complications: Although rare, complications such as infection, nerve damage, or hyperpigmentation can occur. Choosing a qualified and experienced provider can help minimize these risks.
• Minimizing risks: Ensure you choose a skilled dermatologist or cosmetic surgeon who specializes in acne scar treatments. Proper aftercare, including keeping the area clean and avoiding sun exposure, can further reduce risks.

Combining Subcision with Other Acne Scar Treatments

For comprehensive results, subcision can be combined with other treatments:

• Microneedling: Helps stimulate collagen production in the treated area, further improving skin texture.
• Chemical peels: Exfoliates the skin’s surface, reducing the appearance of superficial scars.
• Laser treatments: Can target deeper skin layers and stimulate collagen, improving overall skin tone and texture.
• Dermal fillers: When injected into the area, fillers can plump up the newly released skin, providing immediate improvement.

By combining treatments, patients often experience more dramatic and longer-lasting results.

Subcision is a highly effective treatment for those dealing with moderate to severe acne scars, particularly rolling and tethered boxcar scars. As a minimally invasive procedure with long-lasting benefits, subcision offers a promising solution to smooth out the skin’s texture and restore confidence. For those struggling with acne scars, it may be worth consulting with a dermatologist to see if subcision is the right treatment for you.

Adam Mamelak, MD is an American and Canadian Board Certified Dermatologist and an American Board Certified, Fellowship-Trained Mohs Micrographic Surgeon at Westlake Dermatology. Dr. Mamelak obtained his Bachelor degree and graduated in the top 5% of the Faculty of Science from McGill University, and was a gold medalist (the highest honor obtainable) in his medical class at Queen’s University. He completed his Dermatology residency training at The Johns Hopkins University, where he also completed a research fellowship in Molecular Immunology. Dr. Mamelak completed fellowship training in Mohs Surgery/Procedural Dermatology at the Methodist Hospital in Houston.